Saudi German Hospital · PR-F-1054 — APRIL 2022
Tick each positive finding.
Facial drop
Assymetrical facial movement
Arm drift
Reduced movement of one arm compared to the other
Speech
Slurred or inappropriate words or mute
Time
Less than 4.5 hrs from onset of symptoms
Elapsed since onset
—
If symptoms onset are less than 4.5 hours activate code stroke immediately.
Code Stroke Activated
Time recorded:
Entries auto-save to this device
 | Addressograph | MRN |
| STROKE CODE FLOWSHEET | |||
| STROKE SCREENING: | |||
| Facial drop (assymetrical facial movement) | ☐ Yes | ☐ No | |
| Arm drift (reduced movement of one arm compared to the other) | ☐ Yes | ☐ No | |
| Speech (slurred or inappropriate words or mute) | ☐ Yes | ☐ No | |
| Time (less than 4.5 hrs starting from onset of symptoms) | ☐ Yes | ☐ No | |
| Other symptoms | Specify: | ||
| Onset of symptoms Date: | Time: | ||
| Date of presentation to Emergency Department | Time: | ||
| If symptoms onset are less than 4.5 hours activate code stroke immediately. | ☐ Yes | ☐ No | |
| Code Stroke Activated | ☐ Yes | ☐ No | |
| Date of code stroke activation: | Time: | ||
| INITIALS ASSESSMENT | |||
| 1. Check A B C D's, cardiac monitor attached | ☐ Yes | ☐ No | |
| 2. Intial vital signs time: | |||
| BP: | HR: | RR: | |
| Temp: | RBS: | SO2: | |
| Start on O2 (2 to 4 L/min) nasal cannula to keep on O2 saturation > 94% | ☐ Yes | ☐ No | |
| 3. Establish two IV access. | ☐ Yes | ☐ No | |
| After Arrival of Stroke Team | |||
| Lab sampling (CBC, PT, PTT, INR, serum electrolytes, serum creatinine RBS done? | ☐ Yes | ☐ No | |
| Immediate transfer to CT scan/ MRI ? | ☐ Yes | ☐ No | |
| Perform 12 lead ECG (not to delay transfer to cT scan or receiving IV rtPA) | ☐ Yes | ☐ No | |
| Time of transfer to CT scan: | Time of Transfer to MRI: | ||
| Time of CT Brain interpretation: | Time of MRI interpretation: | ||
| CT Brain excluded hemorrhage. | ☐ Yes | ☐ No | |
| CTA / MRA intracranial / extracranial interpretations: | |||
| Final Diagnosis: | |||
| Treatment Decision: | |||
| Is the patient candidate to IV rtPA (Actilyse) | ☐ Yes | ☐ No | |
| If Yes: Please specify: | |||
| Is IV rtPA consent written: | ☐ Yes | ☐ No | |
| Total calculated dose: | |||
| Time of receiving IV rtPA: | |||
| Door to Needle Time: | |||
| Signs of rTPA Complications | ||||||||||
| Date | Time | BP | GCS | Headache | Vomiting | Bleeding ext./Int. | Hypersinsitivity Reaction | Deterioration of neurological manifestation | Remarks | |
|---|---|---|---|---|---|---|---|---|---|---|
On admission : | ||||||||||
Post CT Scan time: | ||||||||||
TPA starting time: | ||||||||||
| Perform neurological assessment every 5 minutes in the first hour after start of infusion | ||||||||||
| 1st | 5 min.time: | |||||||||
| hour | 10 min.time: | |||||||||
15 min.time: | ||||||||||
20 min.time: | ||||||||||
25 min.time: | ||||||||||
30 min.time: | ||||||||||
35 min.time: | ||||||||||
40 min.time: | ||||||||||
45 min.time: | ||||||||||
50 min.time: | ||||||||||
55 min.time: | ||||||||||
60 min.time: | ||||||||||
| Perform neurological assessment every 15 minutes in the 2nd hour of infusion | ||||||||||
| 2nd | 15 min.time: | |||||||||
| hour | 30 min.time: | |||||||||
45 min.time: | ||||||||||
60 min.time: | ||||||||||
| Perform neurological assessment every 30 minutes in the next 6 hours after infusion | ||||||||||
| 3rd | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| 4th | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| 5th | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| 6th | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| Signs of rTPA Complications | ||||||||||
| Date | Time | BP | GCS | Headache | Vomiting | Bleeding ext./Int. | Hypersinsitivity Reaction | Deterioration of neurological manifestation | Remarks | |
|---|---|---|---|---|---|---|---|---|---|---|
| 7th | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| 8th | 30 min.time: | |||||||||
| hour | 60 min.time: | |||||||||
| Perform neurological assessment hourly from 9th hours untill 24 hours after infusion | ||||||||||
9th hour | ||||||||||
10th hour | ||||||||||
11th hour | ||||||||||
12th hour | ||||||||||
13th hour | ||||||||||
14th hour | ||||||||||
15th hour | ||||||||||
16th hour | ||||||||||
17th hour | ||||||||||
18th hour | ||||||||||
19th hour | ||||||||||
20th hour | ||||||||||
21th hour | ||||||||||
22th hour | ||||||||||
23th hour | ||||||||||
24th hour | ||||||||||
Legend: A-Airway B-Breathing C-Circulation D-Disability RBS- Rondom Blood Sugar BP-Blood Pressure HR- Heart Rate
RR- Respiratory Rate SO2- Oxygen saturation BW- Body Weight CT-Computed Tomograghy ECG- Electrocardiogram
rTPA- recmbinant tissue plasminogen activator IV-Intravenous GCS - Glusgow Coma Scale
| Is the patient candidate for Mechanical Thrombectomy ? | ☐ Yes | ☐ No | |
| Please specify: | |||
| Is Mechanical Thrombectomy consent written: | ☐ Yes | ☐ No | |
| Door to groin puncture Time: | |||
| Please check below & document applicable for announced stroke team | |||
| Arrival of | Name | arrival Time | |
| Core Srtoke team: | (Mandatory attendance) | ||
| ER dept. Physician | |||
| Registered Nurse | |||
| Neurologist | |||
| Nursing Supervisor | |||
| Radiological Tech. | |||
| Radiological doctor | |||
| Lab. Technician | |||
| Neurovascular Interventionalist | |||
| Others: | (Attendance as per needs of the code) | ||
| Comments if any | |||
| Code Summary | |||
| Time to transfer the patient to stroke unit: | Hours: | ||
| Code Result | |||
| ICU admission ☐ | CCU admission ☐ | GW admission ☐ | |
| ER Staying ☐ | |||
| Transfer to another hospital ☐ | Specify: | Date: | Time: |
| Died ☐ | Date: | Time: | |
| Remarks/ Recommendation | |||
| Signatories | |||
| Assigned Nurse Name: | Signature: | Date & Time: | |
| ER Physician Name: | Signature: | Date & Time: | |
| Receiving Nurse Name: | Signature: | Date & Time: | |
| Receiving Unit: | |||
| Neurology Physician Name: | Signature: | Date & Time: | |
| Neurovascular Interventionalist Name: | Signature: | Date & Time: | |